Developing inclusive, collaborative and pluralistic practice
Symposium 1: practitioner research into key therapeutic skills and processes

John McLeod with Diana Salek-O'Reilly, Mark Tolan, Beverley Webster and Tricia Joyce

Symposium overview

Professional role: Visiting Professor
Institute/affiliation: Institute for Integrative Counselling and Psychotherapy, Dublin

Aims of the symposium: A growing body of research evidence suggests that clients value a flexible, collaborative approach to therapy organised around a collaborative process of shared decision-making that allows ideas and methods from both client and therapist to be combined in ways that contribute to the accomplishment of client goals. While many practitioners and therapy providers identify this kind of collaborative stance, the pluralistic therapy professional community has sought to develop a practice framework that is explicitly organised around such principles. The aim of this symposium is to highlight examples of practitioner research that have explored specific aspects of a collaborative, pluralistic approach to therapy.

Contribution of each symposium paper to the overall theme: Establishing a culture of feedback represents a crucial element of any form of therapy practice that seeks to harness the client’s views of what is helpful or unhelpful. Paper 1 reports on an analysis of interviews with clients around their experiences of offering feedback to their therapist. Paper 2 used interviews with therapists to explore the challenges they encountered when introducing feedback measures into their own practice. An important feature of the landscape of collaborative practice is that it includes many therapists whose initial training was in a relatively expert-driven professional therapeutic stance, and who have sought over the course of their careers to adopt a more collaborative or dialogical approach. Paper 3 is based on interviews with therapists in relation to shifts in their practice around the use of a particular therapeutic skill – therapist self-disclosure – that is associated with a collaborative way of working. Paper 4 provides an overview of the implications for inclusive pluralistic practice of a mixed methods pragmatic randomised trial of pluralistic therapy for young people with addictions problems, that incorporated data from both clients and therapists.

Implications of the symposium theme for counselling and psychotherapy theory, research and practice: The studies included in this symposium have important implications for therapy practice, in terms of offering practical ideas about ways of supporting collaborative ways of working, and also implications for the distinctive insights afforded by small-scale practitioner studies, as a counterpoint to other forms of inquiry.

Considerations given to issues of equality, diversity and inclusion: The studies reported in this symposium provide insights into therapist skills and strategies that seek to engage actively with the worldviews, configurations of life experience and adversity, and recovery resources of clients from diverse cultural backgrounds.

Symposium Paper 1
Client experiences of giving feedback to their therapist

Diana Salek-O'Reilly

Aims/purpose: Client-therapist collaboration and shared decision-making represent key elements in approaches to counselling and psychotherapy that seek to be inclusive of client diversity. An essential aspect of effective collaboration involves client feedback to the therapist about the helpfulness of therapy and the quality of the therapeutic relationship. Little is known about the meaning for clients of directly offering feedback to their therapists. The aim of the present study was to investigate the client’s perspective on the process of offering in-session feedback.

Methodology: An exploratory qualitative study was carried out in which 6 clients were interviewed about what it had been like for them to make self-initiated comments to their therapists around how they felt about the therapy they were receiving. Interview questions were based on the Client Change Interview. Participants were also shown copies of widely-used feedback measures, and asked to comment on whether they had been, or might have been valuable in the context of their own therapy experience. Interviews were transcribed and analysed using an IPA approach.

Ethical approval: Ethical approval for the study was granted by the Research Ethics Committee, IICP College, Dublin.

Results/findings: Participants reported that it was hard to offer direct feedback to their therapist, and they largely avoided doing so, choosing instead to conceal their true feelings for fear of how the therapist might react. On those occasions when they did offer direct feedback, a typical response was that nothing changed and/or the therapist reacted in a defensive manner. By contrast, occasions when the therapist constructively engaged with feedback had the effect of enhancing trust, connection, and a sense of being valued. It was important for therapists to directly ask for feedback in a personal manner and for the clients to trust their therapist sufficiently. Establishing a culture of feedback was associated with more productive and satisfying therapy endings.

Research limitations: The study was based on a limited sample of clients – further research needs to be carried out, in different settings and with a greater diversity of clients.

Conclusions/implications: The implications of these findings for counselling practice are that practitioners need to be more aware of both the reluctance of clients to provide them with direct feedback, and the significant benefits that may accrue for clients if this barrier can be overcome.

Symposium Paper 2
From encounter to assimilation: a qualitative study of pluralistic therapists’ lived experience of incorporating routine outcome monitoring into their clinical practice

Mark Tolan

Aims/purpose: Client-therapist collaboration and shared decision-making represent key elements in approaches to counselling and psychotherapy that seek to be inclusive of client diversity. An essential aspect of effective collaboration involves client feedback to the therapist about the helpfulness of therapy and the quality of the therapeutic relationship. There exists an extensive evidence base concerning the effectiveness of using routine outcome and process measures in different contexts, in respect of their capacity to enhance client outcomes. However, it is also clear that many practitioners are unwilling to engage with such practices, or do not obtain good results if required to do so. The aim of the present study was to investigate practitioner learning process in relation to these skilful use of feedback tools.

Methodology: An exploratory study was carried out in which 5 therapists who had been trained to use feedback measures within a pluralistic therapy training programme, were interviewed about what it had been like for them to become competent in relation to this aspect of their work. Interviews were transcribed and analysed using an Interpretative Phenomenological Analysis (IPA) approach.

Ethical approval: Ethical approval for the study was granted by the Research Ethics Committee, IICP College, Dublin.

Results/findings: All informants reported that they had initially been resistant to the use of feedback measures. A crucial aspect of their learning process was support from colleagues and supervisors. In addition, direct experience of using measures in training had significant effects on future attitudes and utilisation. Participants also reported that it had been helpful to them to be able to make sense of the use of feedback tools in relation to the broader theoretical rationale provided by pluralistic therapy.

Research limitations: The study was conducted with a limited sample of informants in a specific cultural and professional context – further research is necessary in order to determine the generalisability of findings.

Conclusions: The findings of this study suggest that learning to use feedback measures can be problematic, even for those who had committed themselves to a lengthy pluralistic therapy training programme that emphasised the value of such procedures. A key take-home message of the study is the importance of local practice-based champions, such as supervisors or mentors, who are able to support learners to make the transition from classroom-based skills learning to application on complex.

Symposium Paper 3
An exploratory study of pluralistic therapists’ views and lived experiences of therapist self-disclosure

Beverley Webster

Aims/purpose: Many collaborative approaches to counselling and psychotherapy that seek to be inclusive of client diversity, such as pluralistic therapy, advocate judicious use of therapist self-disclosure as a means of facilitating shared decision-making. However, many therapists have been trained to avoid personal disclosure to clients. For these practitioners, the shift from a primarily expert-driven stance to a more transparent collaborative stance may involve re-visiting long-held assumptions about self-disclosure. The aim of this study was to contribute to an understanding of how such practitioners experienced the processes of personal and professional learning associated with this kind of transition.

Methodology: Interviews were carried out with four experienced therapists who had completed training in pluralistic therapy following their initial professional training and accreditation as psychotherapists in Ireland. Interviews were transcribed and analysed using an Interpretative Phenomenological Analysis (IPA) approach.

Ethical approval: Ethical approval for the study was granted by the Research Ethics Committee, IICP College, Dublin.

Results/findings: All participants reported that their initial professional training had encouraged them to be cautious about the use of self-disclosure with clients. All of them described themselves as using therapist self-disclosure much more frequently as a result of pluralistic training. In particular, they used self-disclosure in a new way – in conjunction with metacommunication and checking-out, and as a necessary element of client-therapist dialogue. They also reported that research evidence they had read during pluralistic training provided them with valuable guidance and gave them more faith in the value of this skill. Participants also believed that the necessity of adapting their therapeutic approach in the face of the covid-19 pandemic had also influenced them in the direction of using more self-disclosure.

Research limitations: The study was conducted with a limited sample of informants in a specific cultural and professional context – further research is necessary in order to determine the generalisability of findings.

Conclusions: The findings of this study that building a capacity to provide a flexible, inclusive and collaborative form of therapy may be facilitated by opportunities to reflect on how specific skills – such as therapist self-disclosure – may need to be adapted. More generally, the study suggests that a potentially valuable means of developing new insights into the nature of post-qualifying professional development might be to focus on participant experience of shifts in their understanding and application of specific key skills.

Symposium Paper 4
Practice-relevant learning from a mixed methods study of the effectiveness of pluralistic counselling for young people presenting with addiction issues: an RCT without winners and losers

Tricia Joyce

Aims/purpose: There is a growing appreciation that research that contributes to inclusiveness and a just society requires active attention to the issue of epistemic justice (i.e., the voices and perspectives of all participants) in relation to in relation research design, data collection and analysis and the distribution of results. The aim of this presentation is to highlight practice-relevant aspects of findings from a mixed methods RCT that compared counselling as usual with a pluralistic therapy intervention, for young people presenting with issues of addiction.

Methodology: In addition to the administration of standard process and outcome measures, the study involved qualitative analysis of the voices and lived experience of the young person clients, the therapists who undertook the interventions, and the wider community of therapists within the agency in which the study took place. Following a brief account of the findings of the study as a whole, this presentation focuses in detail on areas of convergence and divergence between the views of different sets of participants.

Ethical approval: The study received ethical approval from the Department of Psychology Ethics Committee at the University of Roehampton.

Results/findings: In terms of statistical analysis of quantitative data, the study found no differences in outcome between clients who had received pluralistic counselling and those who had undergone treatment as usual. Mixed methods analysis that synthesised findings from both qualitative and quantitative data sources identified a number of practice-relevant emergent themes: (a) the need to adapt therapy procedures to the worldview of both therapists and clients; (b) the significance of specific aspects of the client-therapist relationship associated with good and poor outcomes; (c) a dialectical process in which the therapy process was shaped by the organisational context in which it took place and the agency was in turn affected by the research.

Research limitations: The findings of the study are grounded in the experiences of clients, counsellors and a researcher in one local counselling service: more generalisable conclusions require further similar studies in other locations.

Conclusions: The study indicates that effective use of a collaborative approach to counselling needs to take account of the cultural context in which therapy is being delivered and demonstrates the practical relevance of conducting small-scale mixed-method collaborative pragmatic RCTs in community settings.

Developing inclusive, collaborative and pluralistic practice
Symposium 2: Building a practical understanding of how to respond to client preferences

John McLeod with Mick Cooper, Joe Bowden and Marcella Finnerty

Symposium overview

Professional role: Visiting Professor
Institution/affiliation: Institute for Integrative Counselling and Psychotherapy, Dublin

Aims of the symposium: Historically, an important way in which client diversity has been investigated in therapy research has been through studies of client expectations, beliefs and attitudes, and the relative credibility of different approaches to therapy. While this body of research has made it possible to identify differences in viewpoint associated with such factors as age, culture, social class, religion, and sexual orientation, they have not generated concrete proposals about how to deliver therapy that is responsive to such dimensions of difference. In recent years, it has become apparent that the closely related construct of client preferences opens up new possibilities about how to make constructive links between therapy processes and client beliefs and expectations. A series of studies and reviews have demonstrated that therapy that is more closely aligned with client preferences is more likely to be beneficial for clients. What is less well understood, at this point, is what it is like for clients and therapists to work together to identify client preferences and then use that that knowledge to inform the process of therapy. Qualitative research into client and therapist lived experience in therapy sessions offers a methodological approach that is appropriate to generating new understandings about how such activities unfold in different therapy contexts.

Contribution of each symposium paper to the overall theme: Paper 1 anchors the symposium in a client perspective by analysing the experiences of clients who had received therapy from practitioners who made systematic use of a client preference measure to support this aspect of the therapy process. Papers 2 and 3 then shift to a therapist perspective, by reporting on interviews with therapists around their experience of engaging with client preferences. Paper 2 is based on interviews with integrative therapists who acknowledge the importance of client preferences - but had not undergone training around this area of practice - around the challenges they encountered in relation to maintaining their responsiveness to client perspectives. Paper 3 reports on the experiences of therapists who had completed a pluralistic therapy training programme in which skills for engaging with client preferences were specifically addressed, in respect of how they addressed client preferences and how these skills had been developed.

Implications of the symposium theme for counselling and psychotherapy theory, research and practice: Taken together, the findings of these studies make it possible to identify effective strategies for facilitating preference-informed collaborative therapy, as well as highlighting areas in which further research is necessary.

Considerations given to issues of equality, diversity and inclusion: The studies reported in this symposium provide some first steps in the direction of new ways of making sense of the processes through which practitioners can facilitate active engagement in therapy of clients from diverse cultural backgrounds.

Symposium Paper 1
Client perspectives on working with preferences in psychotherapy: A consensual qualitative research study

Mick Cooper

Authors: Mick Cooper, University of Roehampton; Gina De Malta, University of Roehampton and The Open University; Sarah Knox, Marquette University, Wisconsin;  Hanne Oddli, University of Oslo, Norway; Joshua Swift, Idaho State University, Idaho

Aim/purpose: Research into assessing and accommodating client preference in psychotherapy has been rapidly expanding, but all studies, to date, have been quantitative. We undertook the first qualitative examination of client preferences to understand how clients experience working with preferences, the nature of client preferences, and its effects.

Design/methodology: Participants were 13 British clients, ten identified as female and three as male, who had up to 24 sessions of a collaborative–integrative psychotherapy. Interviews were conducted at endpoint and analysed using a team-based, consensual qualitative research approach.

Ethical approval: The study received ethical approval from the Department of Psychology Ethics Committee at the University of Roehampton.

Results/findings: Three superordinate domains were established (alongside contextual findings): the preferences themselves, the process of working with preferences in psychotherapy, and the effect of preference work and its absence. Clients predominantly wanted leadership, challenge, and input from their psychotherapist; and a warm and affirming style. Preferences originated either from the clients’ personal history, characteristics, or circumstances; the present psychotherapy; or past episodes of psychotherapy. While some preferences changed over time, others did not. Clients experienced preferences as being explicitly communicated and accommodated, but in some cases this process was implicit. Preference work generally had a positive effect, both in terms of the therapeutic relationship and the client’s intrapersonal world. However, not accommodating client preferences was at times also beneficial.

Research limitations: Generalisability of our findings are limited by the small sample size, the specific nature of the therapeutic intervention, potential researcher biases, and the predominantly white nature of our sample.

Conclusions/implications: Our findings provide important qualitative triangulation to quantitative evidence on therapy preferences. Preference origins, and facilitative/inhibiting factors, are identified for the first time. Through qualitative research, we have identified nuances of preference work and the need to tailor it to particular clients, preferences, and points in time.

Symposium Paper 2
Client preferences in therapy – the therapist perspective

Joe Bowden

Aim/purpose: Client-therapist collaboration and shared decision-making represent key elements in approaches to counselling and psychotherapy that seek to be inclusive of client diversity. An essential aspect of effective collaboration is the therapist’s capacity to elicit client preferences and use this information to inform shared decision-making about therapy activities as well as practical factors such as number and timing of sessions. Previous research on client preferences has evaluating the extent to which preference accommodation is associated with outcome, and on client experience of being invited to identify their preferences. The aim of the present study was to explore the experience of preference-informed practice from the point of view of the practitioners, with a particular focus on the perspective of therapists who were personally and ethically committed to working in a client-responsive and flexible manner but who have not undergone specific training in preference-informed practice.

Design/methodology: An exploratory study was carried out in which seven experienced therapists who identified themselves as practicing integrative or eclectic therapy, were interviewed about their ways of responding to client preferences. Interviews were transcribed and analysed using a reflexive thematic analysis approach.

Ethical approval: Ethical approval for the study was granted by the Research Ethics Committee, IICP College, Dublin.

Results/findings: While all informants reported that in principle they accepted the value of aligning therapy with client preferences, they all acknowledged that this aspect of their work presented them with considerable challenges. They understood preferences in terms of their own capacity to respond flexibly to their clients and ‘go that extra mile’ and observed that in recent years the majority of clients had become more knowledgeable about the therapy options that were available to them. In general, over the course of interviews, informants struggled to describe specific instances of preference-informed practice and reflected that they were aware that it could be valuable for them to learn more about this aspect of therapy. They did not provide any examples of potentially unhelpful episodes of responsiveness to client preferences.

Research limitations: The study was conducted with a limited sample of informants in a specific cultural and professional context – further research is necessary in order to determine the generalisability of findings.

Conclusions/implications: The findings of the present study suggest that a general appreciation of the helpfulness of attending to client preferences appears to have become part of received wisdom, at least in the professional community within which participants in the study belonged, there may be a need for further training opportunities and published material that would allow practitioners to develop specific skills and strategies. The findings of the study also suggest that it may be valuable for future studies of the relationship between client preferences and therapy outcomes might usefully incorporate ratings of therapist knowledge and skills around this area of practice.

Symposium Paper 3
How do pluralistic therapists engage with client preferences?

Marcella Finnerty

Authors: Marcella Finnerty and Caitríona Kearns, IICP, Ireland

Aim/purpose: Recent reviews of available research suggest that – in any type of therapy - clients whose preferences are considered, ultimately stay longer in therapy, have better relationships with their therapists and experience better outcomes. On the grounds that “what works for one person may not work for another,” the topic of how to understand, elicit and accommodate client preferences has comprised a central aspect of pluralistic and other collaborative and inclusive approaches to therapy. However, although there exists a wealth of research into client preferences, and pluralistic therapy textbooks contains ubiquitous references to client preferences, research into how pluralistic therapists actually utilise and explore preferences in their work is not abundant. In the light of these considerations, the aim of the present study was to explore how experienced pluralistic therapists utilise client preferences in their day-to-day clinical work in a private practice and/or setting.

Design/methodology: Five experienced pluralistic psychotherapists were invited to participate in a qualitative interview with the researchers. All interviewees were graduates of a Master’s Degree in Pluralistic Counselling & Psychotherapy so had completed a formal training in Pluralistic practice. All had worked for more than 10 years as therapists and had completed their pluralistic therapy training at least five years prior to being interviewed. A recorded semi-structured interview occurred and data were analysed using Reflexive Thematic Analysis.

Ethical approval: Ethical approval for the study was granted by the Research Ethics Committee, IICP College, Dublin.

Results/findings: Participants were able to describe multiple examples of preference-informed practice. A key theme that emerged was that therapists in this study focused more on treatment and activity preferences, and less on therapist preferences (e.g., the age, gender or ethnicity of the therapist). There appeared to be an assumption made about the clients self-selecting the therapists, and therefore automatically demonstrating their preference in this domain. Therapists interviewed in this study described both formal and informal methods for exploring preferences. Tools such as the C-NIP or HAT were used to explore what clients both wanted from therapy, and what they found helpful or unhelpful in therapy. Alongside this, participants described an ongoing dialogical process where exploration of preferences occurred in an ongoing manner, throughout the therapy process. Some participants described a ‘transformative’ experience in their practice, where a focus on preferences had, in their view, led to improved outcomes and retention rates. No examples of unhelpful preference-oriented processes were reported.

Research limitations: The study was conducted with a limited sample of informants in a specific cultural and professional context – further research is necessary in order to determine the generalisability of findings.

Conclusions/implications: The findings of this study suggest that post-qualifying training in pluralistic therapy is capable of producing practitioners who view themselves as being competent and confident in respect of their ability to be responsive to client preferences, and have been able to sustain these attitudes and skills over a period of several years. It could be useful for future studies of the relationship between client preferences and therapy outcomes to focus on outcomes and therapy processes associated with practitioners with such profiles, as a means of developing a clearer understanding of expertise around working with preferences. In addition, more needs to be known about the ways in which preference accommodation is maintained in situations of marked socio-cultural difference between client and therapist.

Short-term Psychotherapy for Depressed Adolescents: Examining patients' symptoms, personality dimensions, and their psychotherapy processes

Guilherme Fiorini with Yushi Bai, Antonella Cirasola and Elizabeth T Yi

Symposium overview

Professional role: PhD Candidate
Institution/affiliation: University College London (UCL) and the Anna Freud National Centre for Children and Families

Aims of the symposium: This symposium presents different studies all attempting to understand different aspects of adolescent depression and its treatment, including patients’ personality dimensions, the dynamics of the patient-therapist relationship, and epistemic trust in the therapy process.

Contribution of each symposium paper to the overall theme: The first paper focuses on the examination of patients’ personality dimensions of self-criticism and dependency, and how they relate to this population’s overall functioning. The second paper comprises a single-case study examining the alliance-rupture process in a successful treatment. This paper also offers a preliminary model of how to explore and repair alliance ruptures in Short-Term Psychoanalytic Psychotherapy (STPP). The third paper examines the in-session interactions between patient and therapist in STPP, comparing good and poor outcome cases (n=10). This study’s findings include insights about both patients’ and therapists’ behaviours and interactions that may be associated with successful and unsuccessful treatments. The fourth and final paper addresses the theme of resolution of epistemic mistrust in psychotherapy for depressed adolescents in STPP, Cognitive-Behavioural Therapy (CBT) and a Brief Psychosocial Intervention (BPI). This study examines the micro-process level of resolution (or non-resolution) of epistemic mistrust, comparing good (n=4) and poor (n=2) outcome cases.

Implications of the symposium theme for counselling and psychotherapy theory, research, and practice: The papers contained in this symposium offer researchers and clinicians insights into the diverse experiences that may fall into the umbrella term ‘depression’, and what factors are associated with them. The empirical findings presented also shed light on what factors may be associated with good and poor outcomes in youth psychotherapy. These include working on repairing alliance ruptures, promoting collaborative interactions between the dyad, and paying attention to signs of aggression that may appear during the sessions.

Considerations given to issues of equality, diversity, and inclusion: All papers in this symposium were part of a larger investigation, the IMPACT trial. Although the IMPACT trial sample was representative of the UK’s general population, it is worth highlighting that 82% of its overall sample was white. Given that the trial took place in England, we acknowledge that this study was based on a WEIRD (Western, Educated, Industrialized, Rich, and Democratic) context, and further replication in other settings is necessary.

This session will help you:

  • Identify what types of problems are associated with different experiences of depression in youth (i.e., self-criticism and dependency).
  • Consider a preliminary model of how to explore and repair alliance ruptures in Short-Term Psychoanalytic Psychotherapy.
  • Understand what types of in-session interactions and behaviours are associated with good and poor outcomes when treating adolescents with depression.

Symposium Paper 1
Self-criticism and Dependency in Young People with Major Depressive Disorder: Associations with Clinical Features and Psychological Functioning

Yushi Bai

Authors: Yushi Bai, University College London and The Anna Freud National Centre for Children and Families; Patrick Luyten, University College London (UCL), The Anna Freud National Centre for Children and Families and University of Leuven, Belgium.

The personality dimensions of self-criticism and dependency have been shown to confer vulnerability for depression in adults. However, the evidence for an association between these personality dimensions and depression in adolescence is weaker, particularly because most studies in this area have been conducted in non-clinical samples.

Aim/purpose: The current study therefore aimed to examine potential associations between self-criticism, dependency and indices of intrapersonal and interpersonal functioning in a large sample of clinically depressed adolescents.

Method: 465 adolescents with depression diagnoses were included. Correlation and multiple regression were used to investigate associations between dependency, self-criticism, their interaction of each other, and their interaction with gender on indices of intrapersonal (e.g., depression, anxiety, antisocial behaviour, obsessional-compulsion, suicidality, self-esteem and rumination), and interpersonal (e.g., friendship, family functioning and parenting) functioning.

Ethical approval: The study protocol was approved by the Cambridgeshire 2 Research Ethics Committee, Addenbrookes Hospital Cambridge, UK.

Results/findings: Consistent with findings in adult populations, self-criticism was more consistently associated with indices of maladaptive functioning, whilst results for dependency were more mixed. There was also evidence for gender incongruence effect in that dependency in boys or self-criticism in girls was associated with higher levels of anxiety, obsessive-compulsive symptoms and present suicidal ideation.

Research limitations: The current study adopted a cross-sectional design; therefore, we are unable to untangle causal relationships between variables. Moreover, all the analyses were based on the sample diagnosed with moderate to severe depression. The potential impacts of the sample nature should be considered when interpreting findings relating to other clinical syndromes and functioning.

Conclusions/implications: To our knowledge, the current study is the first to adopt a large clinical adolescent sample with depression diagnosis to evaluate the role of personality vulnerabilities of dependency and self-criticism on a wide range of functioning. The current study observed different patterns in terms of dependency and self-criticism relating to clinical conditions. Such findings not only indicate the value of considering adolescent personality vulnerabilities in both psychopathology research and clinical practice, but also suggest further studies to investigate the underlying mechanisms of the observed difference in terms of dependency and self-criticism associating with different mental disorders.

Symposium Paper 2
Alliance Ruptures and Resolutions in Short-Term Psychoanalytic Psychotherapy for Adolescent Depression: An empirical case study

Antonella Cirasola

Authors: Antonella Cirasola, Peter Martin, Peter Fonagy and Nick Midgley, University College London; Catherine Eubanks, Yeshiva University, New York and Christopher Muran, Adelphi University, New York

Most research on alliance rupture-repair processes in psychotherapy has been carried out with adults and little is known about the alliance dynamics with adolescents, especially in psychodynamic treatments.

Aim/purpose: This study aimed to better understand the process of alliance rupture-resolution and its role in a good-outcome case of a depressed adolescent treated with short-term psychoanalytic-psychotherapy (STPP).

Design/methodology: A longitudinal, mixed-methods empirical single-case approach was employed. Multiple sources of information (questionnaires, interviews, sessions recordings) from various perspectives (adolescent, therapist, observer) were assembled and analysed.

Ethical approval: The study protocol was approved by a UK National Health Service ethics committee. Fully informed written consent was obtained. Details about the backgrounds of the patient and therapist have not been reported and some information has been changed to preserve anonymity.

Results/findings: The different sources of evidence converged and showed that, despite the presence of frequent alliance ruptures, patient and therapist managed to resolve these and develop a good and collaborative relationship. Both patient and therapist regarded the evolution in their relationship as the treatment factor mainly responsible for the positive changes experienced by the adolescent. Based on both theoretical and empirical data, a preliminary model of how to explore and repair alliance ruptures in STPP is presented.

Research limitations: As this study included only one case, its findings cannot be immediately generalised beyond the specific patient and therapist dyad and/or treatment type. Furthermore, due to the absence of a control condition, causal conclusions about the relationship between alliance rupture resolutions and outcomes cannot be made.

Conclusion/implications: This study illustrates one way of applying an empirical, mixed-method approach to a single-case. Its finding supports the idea that, although the resolution of alliance ruptures can be a challenging and uncomfortable process for both therapist and patient, its competent management can ultimately foster deeper exploration of relational patterns, strengthen the patient-therapist relationship and foster positive therapeutic change.

Symposium Paper 3
The short-term psychoanalytic psychotherapy process with depressed adolescents: comparing good and poor outcome cases

Guilherme Fiorini

Authors: Guilherme Fiorini, Yushi Bai, Peter Fonagy and Nick Midgley, University College London (UCL) and The Anna Freud National Centre for Children and Families

Aim/purpose: Despite the growing evidence indicating that psychoanalytic interventions are effective in the treatment of adolescent depression, little is known about how and why patients improve, and what is associated with successful and unsuccessful interventions for youth. To contribute to filling this gap, the present study aimed to identify and describe in-session interaction patterns between psychoanalytic therapists and young people diagnosed with major depressive disorder, comparing good and poor outcome cases.

Design/methodology: The audio recordings for 100 psychotherapy sessions from 10 Short-Term Psychoanalytic Psychotherapy (STPP) cases were analysed using the Adolescent Psychotherapy Q-Set (APQ). The APQ is a measure that is used to describe a psychotherapy session with adolescents, including items referring to the adolescent’s and the therapist’s feelings and behaviours and the interaction between the dyad. The sessions were drawn from 10 cases, evenly divided into two groups (poor outcome and good outcome, 50 sessions per group). The sessions ratings were submitted to an oblique Exploratory Factor Analysis (EFA), to unfold identifiable patterns. Group differences in these factors were then assessed through t-tests.

Ethical approval: The IMPACT study was approved by the Cambridgeshire 2 Research Ethics Committee, UK (09/H0308/137).

Results: The EFA revealed three factors:

  1. ‘Open, engaged young person working collaboratively with a therapist to make sense of their experiences’
  2. ‘Directive therapist with a young person fluctuating in emotional state and unwilling to explore’
  3. ‘Young person expressing anger and irritation and challenging the therapist’.

Factor 1 was significantly more prominent in the good outcome cases, while factor 3, on the opposite direction, was more significantly related to the poor outcome cases. Factor 2 was equally present in both groups.

Research limitations: Due to this study’s design and data availability, we could not draw any causal relations between the variables investigated. Implications: Besides reinforcing to researchers and clinicians the association between a collaborative psychotherapy process with good outcomes, our findings also provide empirical data regarding the role of aggression in adolescent depression. Furthermore, we also discuss directedness as a feature in psychoanalytic psychotherapies for youth.

Symposium Paper 4
The Resolution of Epistemic Mistrust in Psychotherapy: A task analysis

Elizabeth T Yi

Authors: Elizabeth T Yi, Nick Midgley and Chloe Campbell, University College London (UCL) and The Anna Freud National Centre for Children and Families; Patrick Luyten, UCL, The Anna Freud National Centre for Children and Families and the University of Leuven, Belgium.

Aim/purpose: Although the theoretical model for epistemic trust in the context of psychotherapy has been clearly articulated and the theory of epistemic trust has started informing research in psychotherapy, no study has yet explored a resolution of epistemic mistrust in psychotherapy. This study aims to address the gaps by exploring how epistemic mistrust is resolved in psychotherapy in a purposive sample of six depressed adolescents selected from the Improving Mood with Psychoanalytic and Cognitive Behaviour Therapy (IMPACT) study, a randomized controlled trial comparing three interventions (i.e., CBT, STPP, BPI) in the treatment of depression in adolescents.

Design/methodology: A diverse sample was selected in the analysis, including “White British” (N = 3), “Asian or Asian British” (N = 2), and “Any Other Mixed Background” (N = 1). Using task analysis, this study assesses Fonagy and colleagues’ (2019; 2020) ideal, rational model of three communicative processes and compares “successful” cases (N = 4) with “unsuccessful” cases (N = 2) to develop a synthesis rational-empirical model that resolves epistemic mistrust in psychotherapy across different treatment arms.

Ethical approval: The IMPACT study protocol was approved by the Cambridgeshire 2 Research Ethics Committee, Addenbrookes Hospital Cambridge, UK (Reference 09/H0308/137).

Expected results: The task-analysed psychotherapeutic process will be described at a micro-process level. We predict that the rational-empirical model follows the overlapping and reiterative sequence of the three communicative processes.

Conclusions/implications: In the synthesis rational-empirical model, we can learn whether there are detectable warning signs of patients’ epistemic mistrust in early sessions and what therapeutic techniques can facilitate epistemic openness and mentalizing. Moreover, we may be able to know which of the three therapeutic approaches (i.e., CBT, STPP, BPI) might be most effective in reducing epistemic mistrust and whether the process of resolving epistemic mistrust is a shared mechanism for change, and whether restored epistemic trust is a common outcome in psychotherapy, regardless of therapeutic orientations and skills. 

The PCEPS-10: What have we learned? How could it be improved? Is cultural empathy missing?

Robert Elliott with Richard Doyle and Rinda Haake

Symposium overview

Professional role: Associate Researcher
Institution/affiliation: University of Strathclyde

Moderator: Robert Elliott, University of Strathclyde
Presenters: Richard Doyle, University of Nottingham; Rinda Haake, University of Sheffield

Aims of the symposium: The ten-item version of the Person-Centred and Experiential Psychotherapy Scale (PCEPS-10) was developed as a treatment integrity measure for use in outcome research on person-centred-experiential counselling and psychotherapy. However, over the past ten years, it has been used to assess counsellors applying for accreditation to deliver Counselling for Depression in IAPT services in England. The primary purpose of this symposium is to provide an update of what we know about the PCEPS, based on research by three different research teams in the UK. Along with their specific interests, the presenters will report inter-rater reliability and inter-item/factor structure of. Overall, we aim to provide an appraisal of the strengths and limitations of the PCEPS, as well as discussing future directions and possible revisions, including adding items relevant to equality, diversity and inclusion.

Contribution of each symposium paper to the overall theme: Each of the presenters addresses the application of the PCEPS-10 in a different setting, providing data on inter-rater reliability and inter-item reliability/factor structure in order to evaluate the PCEPS-10 and to provide recommendations for possible revisions: First, Price and colleagues use a large data set of real-world PCEPS assessments by expert trainers rating counsellors in a Counselling for Depression (CfD) supervision/accreditation programme. Second, Haake and colleagues report reliability and item structure analyses for the PCEPS-10 using expert raters in the context of the recent, large scale PRaCTICED trial. Then, uniquely, they use rater qualitative written comments to get inside the expert raters’ experiences. Finally, Elliott et al. use a naturalistic, randomly selected research clinic sample to dig into the PCEPS psychometrics using student raters, with a focus on convergent validity.

Implications of the symposium theme: PCEPS is an important measure and is used in high-stakes testing; however, this use has not been supported by sufficient psychometric research. For this reason, an evaluation of its strengths and weaknesses is overdue, and perhaps could lead to an improved PCEPS 2.0.

Considerations given to issues of equality, diversity and inclusion: Recent increased awareness of issues of equality, diversity and inclusion raise questions about whether measures like the PCEPS adequately assess counsellors’ sensitivity to the impact of social and cultural context on clients, including the impact of social inequality, exclusion and micro-aggressions. Each of the three sets of presenters has been asked to look at the PCEPS with this lens and to consider whether adding a “contextual/cultural empathy/acceptance” item is warranted.

Symposium Paper 1
Interitem and interrater reliability of the PCEPs 10 as used in the assessment of adherence on the PCE-CfD training programme

Richard Doyle

Authors: Emma Tickle, Richard Doyle, Dr Sue Price and Catherine Hayes, University of Nottingham

Aim/purpose: The PCEPs is a high stakes measure in the assessment of adherence to the PCE-CfD manual for therapists delivering counselling in IAPT. This study aims to explore how the measure performs in practice in a real-world setting. A factor analysis hopes to reveal underlying dimensions implying a more concise measure. Agreement between assessors’ scoring will be correlated to measure interrater reliability.

Design/methodology: An exploratory factor analysis of 100 assessments will be conducted to reveal underlying dimensions and how these factors are structured. Interrater reliability, of 50 assessments, will explore the agreement between assessors on those assessments that have been second marked. The study will also provide descriptive data for mean PCEP scores and completion rates of 486 (approx) IAPT therapists who started their PCE-CfD training with the University of Nottingham, between 2013 and 2021.

Ethical approval: This is an evaluation of archival data collected for educational purposes and therefore did not require formal ethical approval.

Results/findings: We expect interrater reliability to be high. We also anticipate there will be a small number of facilitative factors which most items will load on to. We also anticipate there may be redundant items in the PCEPS 10, where some items may need to be collapsed, into one. From previous research conducted in 2017 descriptive statistics will be expected to show that of those delegates who complete they are most likely to do so within 15 months, with a mean submission of four recordings and a mean score of 48 out of 60.

Limitations: The excerpts of therapy that were assessed were small and, therefore, may not assess the therapy in general. In addition, being a quantitative measure, may not pick up on a more global impression of the therapist. Some raters rated the same therapist more than 4 times and this, therefore, may have given the rater a more global impression of the therapist. However, these limitations are an essential element of this study having ecological validity, as it is how the PCE-CfD have been applied in a real-world setting in a specific context. Interrater reliability may be inflated due to the small sample consisting of “near misses” that is those the first marker scored as 40 and below.

Conclusions/implications: It is expected that this piece of research will result in a more reliable measure which evidences validity. This will make it appropriate to be used in RCTS as well as training, professional accreditation, and CPD.

Keywords: counselling process, reliability/validity, factor analysis, PCEPS, IAPT, assessment, adherence, Person-Centred Experiential Counselling for Depression (PCE-CfD).

Symposium Paper 2
PCEPS in the PRaCTICED Trial: Reliability and rater experience

Rinda Haake

Authors: Rinda Haake, David Saxon, Michael Barkham, Gillian Hardy and Phillippa Harrison, University of Sheffield.

Keywords: Treatment integrity, person-centred-experiential psychotherapy, Counselling for Depression, qualitative research

Aims/purpose: Therapist adherence to the person-centred experiential therapy (PCET) model in the PRaCTICED trial was assessed by four raters using the Person-Centred Experiential Psychotherapy Scale (PCEPS). Raters scored 15-minute middle segments from recordings of 48 representative therapy sessions. This study aims to build a rich description of PCET practice by analysing raters’ free text comments.

Design/methodology: All comments for 48 rated recordings were analysed from a generic descriptive-interpretive approach, using NVivo 12 software, to identify themes within the data. In addition, reliability and item structure analyses for the PCEPS-10 were carried using the same expert raters.

Ethical approval: Ethics approval was granted by the Health Research Authority (Research Ethics Committee 14/YH/0001).

Results/findings: A priori themes such as Tracking and Acceptance were derived from the PCEPS. Empathy and the inter-relatedness of PCEPS items also emerged as themes. Raters commented that these therapist skills facilitate clients in exploring, deepening, and transforming emotions. New themes identified were therapist intention and missed opportunities. Raters commented that when therapist interventions do not flow from acceptance, empathy and tracking, they may divert the client’s experiential flow, and observed that where therapists lacked these skills, they were more directive or dominant in the segments being rated. Reliability and item structure analyses will also be reported.

Research limitations: Findings are based on a small number of raters, assessing a small number of short segments. Raters only provided brief free text comments where moments of practice stood out to them, and therefore descriptions of more and less adherent practice are derived from a limited number of outlying examples.

Conclusions/implications: Themes identified suggest that the raters view acceptance, empathy and tracking as interdependent in good PCET practice.

Symposium Paper 3
A Convergent Validity Study of the PCEPS-10

Robert Elliott

Authors: Robert Elliott, University of Strathclyde; Katie Hinshaw, Sarah Stewart, Zoe Zhang, Abigail Chua, Liam O’Hare-Rennie, Sufia Sattar and Sharon Joyce

Keywords: Assessment, Treatment integrity, person-centred-experiential psychotherapy, Counselling for Depression.

Aim/purpose: Our main purpose was to test the convergent validity of the standard observer version of the PCEPS-10 by comparing it to a recently-developed therapist self-report version. We also wanted to look more closely at inter-rater reliability and factor structure, and to compare it to other measures of relational quality in PCE counselling/psychotherapy.

Design/methodology: Over five-month period seven postgraduate students in a one-year fulltime person-centred counselling/psychotherapy MSc course trained on the PCEPS-10, first rating 38 practice segments, then rating 67 main study segments, drawn from a total of 53 audio-recorded sessions of person-centred counselling in the Strathclyde Counselling Research Clinic. Sessions were carried out by trainee counsellors (not known to raters) in a mostly-free community-based counselling research clinic serving a general outpatient population.

Ethical approval: This study was approved within the research clinic’s generic ethics protocol by  the University of Strathclyde Ethics Committee.


  1. Inter-rater reliabilities: Mean inter-rater correlations (single rater reliabilities) were poor for all items and scale mean, but alphas for combined raters were good to excellent with the exception of Clarity of language (.67).
  2. Inter-item reliability was .93, with excessively high (>.8) intercorrelations for 9 (out 45 unique correlations).
  3. Convergent validity: Main analysis, correlation with therapist self-report PCEPS, was -.16 (n = 34 sessions); observer PCEPS scores were also not associated with Client WAI (-.05) or Client TRS (.17); however, we found a substantial relation with counsellor TRS (.44, p < .01).

Research limitations: In spite of extensive training and various procedures to enhance reliability, the observer version of the PCEPS continues to fall short on inter-rater-reliability, requiring an impractical number of raters (4-6 by our estimate). The convergent validity of the PCPES-O was low, especially with counsellor PCEPS and client session ratings. It is also too long, indicated by excessively large inter-item reliability. At the same time it lacks an item on acceptance/empathy for cultural context, diversity and disadvantage.  We question the validity of student counsellor PCEPS self-ratings (they rated themselves a full point higher, at supervisor level). Finally, the sample size was small.

Implications: Our study suggests that PCEPS rating requires at least four raters. However, more work needs to be done to improve PCEPS reliability and validity, which might be helped by reducing it to five items and rating shorter segments (e.g. five min or shorter). Conversely, it may be better to use more experienced counsellors as raters.

Web-based therapies as a catalyst for more inclusive therapeutic practices

Terry Hanley with Louisa Salhi, Emily Banwell, Santiago De Ossorno Garcia and Siddhi Jain

Symposium overview

Professional role: Reader in Counselling Psychology
Institution/affiliation: University of Manchester

Aims of the symposium: Covid-19 has acted as a catalyst for the development of web-based therapies. Prior to this, many of those involved in creating such provision were doing so to fill gaps in existing provision or make therapeutic support more inclusive and accessible. These services have commonly prized the personal choices of those accessing services, over rigid infrastructures, with a view to making therapy more accessible to individuals who may not ordinarily access it. This symposium therefore reflects upon four projects that examine developing pluralistic web-based practices with a view to discussing how technology can be a means of making therapy more inclusive.

Contribution of each symposium paper to the overall theme: This symposium begins with a presentation outlining how usage of the web-based therapy service for young people and young adults, Kooth, changed over the early months of the global pandemic. Following this, two papers are presented which reflect the way that such services attempt to be guided by the wants and needs of the individuals seeking support. The first outlines the findings from a study investigating the therapy goals, collected using a Goal-based Outcome Measures (GbOM), of adult service users of the The second paper then moves on to discuss the development of a new measure for working online with young people who access a single session of therapy, the Session Wants and Needs Outcome Measure (SWAN-OM). In contrast to traditional psychometric measures, both the GbOM and SWAN-OM intend to place the client in the driving seat of the therapeutic process that follows. The final presentation then moves on to consider the experiences of trainee therapists who have transitioned to web-based work during the pandemic.

Implications of the symposium theme for counselling/psychotherapy theory, research and practice: As is evident above, web-based services are being developed to make therapy more accessible, whilst placing the client’s wants and needs at the centre of therapeutic work. The projects presented here provide an insight into the way that some web-based practices might be viewed as being radical in nature and be pushing the boundaries of more traditional counselling and psychotherapy theory.

Considerations given to issues of equality, diversity and inclusion: Central to this symposium is the notion that web-based therapies have the potential to act as a catalyst for making therapy more inclusive. In addition to increasing the access of therapy to those who might not ordinarily access it, innovative practices are being adopted to amplify the voice of those seeking support. As a consequence, learnings from web-based practices also have the potential to influence in-person therapy.

Symposium Paper 1
Alienated and unsafe: Life through the Covid-19 lockdown for vulnerable young people (aged 11-24 years) as revealed in web-based therapeutic sessions with mental health professionals

Louisa Salhi

Authors: Charlotte Mindel and Crystal Oppong, Kooth Digital Health; Louisa Salhi, Kooth Digital Health and University of Kent; Joanna Lockwood,  University of Nottingham

Aims: The Covid-19 pandemic and subsequent lockdowns have detrimentally and disproportionately affected young people, with those who are considered vulnerable due to their experiences or life circumstances disadvantaged further still. We aimed to understand the experiences of vulnerable young people accessing web-based therapeutic support during the pandemic and early lockdown in the UK, as revealed through the observations of mental health professionals. Through this we aim to explore how services can be more inclusive to support CYPs who are vulnerable, providing learnings that wider services can explore when supporting vulnerable CYPs during the pandemic recovery.

Design and methodology: Four focus groups were conducted with twelve web-based mental health professionals from a digital mental health service. Experiential inductive-deductive framework of thematic analysis was used. The unique approach meant that the experiences of vulnerable young people were highlighted from the professional viewpoint of the practitioners. Participatory workshops with young people with diverse experiences supported the study design, through the co-design of the focus group topic guide and the interpretation and validation of analysis.

Ethical approval: The study was approved by the University of Exeter Ethics Committee [eCLESPsy001970].

Results: Four main themes and additional sub-themes were identified relating to the experiences of vulnerable young people on a web-based mental health platform. These were Escalation of risk, The Experience and Consequence of Loss, Feeling Supported and Empowered, and Feeling Separate and Isolated.

Research limitations: This study explores CYP experiences during counselling through the lens and perspective of practitioners. We recognise this adds a level of removal from the researchers and the CYPs. Practitioners were also living through the same pandemic and thus may have been swayed or influenced by their own experiences when reporting on noteworthy CYP experiences.

Conclusions: Findings broadly suggest that those with existing vulnerability face increased risk of poor outcomes through the pandemic and the restrictions of lockdown, but evidence is also provided of positive outcomes from lockdown and its function as a catalyst for change. Results reinforce that focused and inclusive support for vulnerable young people is a priority as we emerge from lockdown and points to support and protective factors of relevance to online and offline support provision. The study uniquely contributes qualitative insight from web-based mental health professionals who have provided continuity of care to vulnerable youth from pre-pandemic and during lockdown and are therefore well-positioned to understand the impact of lockdown on the lives of service users.

Symposium Paper 2
The use of goal-based outcome measures in web-based therapy with adults: What goals are set, and are they achieved?

Emily Banwell

Authors: Emily Banwell and Terry Hanley, University of Manchester; Louisa Salhi, Nicole Facey-Campbell and Aaron Sefi, Kooth

Aim/purpose: Working to identify an individual's therapeutic goals is one means of making therapy more inclusive. This can help to place the client at the centre, with therapist and client collaboratively working, to decide the focal points of therapeutic work. Goal-based Outcome Measures (GbOMs) are increasingly used to harness discussions, and monitor goal progress. The use of GbOMs has, however, received little attention to date with adult clients. Consequently, this project provides a detailed analysis of the way that routine GbOMs have been used in an anonymous web-based therapy service.

Design/methodology: A cross-sectional design was adopted, to explore the use of goal-focused pluralistic therapy in web-based work with adults. This project analyses routine evaluation data from the web-based therapy service Qwell: an anonymous text-based service that is free at point of delivery. Descriptive and inferential statistics are used to explore data from 557 users.

Ethical approval: All data used in this study was anonymous, and came from service-users who consented to their data’s use in research. Owing to this, ethical review from the lead authors’ institution was not required. Ethical principles and good practice guidelines were, however, followed.

Results/findings: 1,242 goals were collectively set, with a mean average of 2.23 set per person. Of those who engaged with the service for more than one day, 31.6% of goals were recorded as fully achieved and the mean average movement was 4.35 out of a possible 10. Goals relating to signposting were frequent, with good progress made towards achieving them. Goals set collaboratively with a practitioner were also attained to a higher level than those set alone.

Research limitations: This study utilised routine evaluation data from an existing web-based service. Whilst the dataset was incomplete in places, a helpful reflection on real world situations is provided, and analyses of the data highlighted the inherent complexity of anonymous web-based provision.

Conclusions/implications: Analyses of GbOMs provided helpful insight into how adult clients utilised an anonymous web-based provision. Although nuances associated with the online environment must be considered, GbOMs appear a useful way of monitoring therapeutic progress with adults. The results indicated that therapeutic goals that are developed collaboratively between therapist and client appear to result in more progress towards goal completion than self-set goals do, and highlighted the role of web-based services in a wider mental health and wellbeing ecosystem.

Symposium Paper 3
The development of a brief outcome measure for single-sessions of web-based support. The Session Wants and Needs Outcome Measure (SWAN-OM)

Santiago De Ossorno Garcia

Authors: Santiago De Ossorno Garcia and Aaron Sefi, Kooth; Louisa Salhi, Kooth and University of Kent; Terry Hanley, University of Manchester

Purpose: This research describes the development of The Session Wants and Needs Outcome Measure (SWAN-OM) a digital measure for children and young people that aims to capture in-session goals for single-sessions that are client-led and inclusive.

Design/methodology: A four-stage process was followed to develop the instrument inside a digital context:

  1. classical item generation
  2. content and
  3. face validity testing with practitioners and experts, and
  4. a user-experience testing with young people from diverse backgrounds and neurodivergence.

The iterative methodology was used to place the needs of the young people and practitioners at the centre of the inclusive design process.

Ethical approval: The research was reviewed by academics, clinicians’ members of BACP, and an advisory board at Kooth plc. No further ethical review by a committee was sought. All data used in this study was anonymous, and came from service-users, experts and practitioners who consented to their data being used for research purposes.

Results/findings: For phase 1 46-items were initially developed using a service theory for single-sessions. At phase 2 34-items remained using content validity indexes collected from experts. In phase 3, the instrument was piloted at the service. The results show early indications of young people finding the measure helpful in achieving their single-session wants and needs; only 9% of participants said that were not met. The majority of participants (83.9%) selected between one to four ‘in-session’ goals. Practitioners and young people perceived SWAN-OM as an instrument that helped focus the chat and provided a framework for the conversation. Phase 4 user experience workshops with children and young people reveal a different structure to display SWAN-OM, reduction and changes of items, and a free-text personalised item. The final set of 20-items was surveyed by young people to assess comprehensiveness, all 20-items scored on average 7.54 (SD=0.53).

Research limitations: The development of a measure based on a specific service theory limits its generalisation. An iterative development process responsive to stakeholders needs causes limitations by involving multiple participants and methodologies with competing evidence. There could be social desirability on outcomes for SWAN-OM, despite the lessened effect seen in digital contexts.

Conclusions/implications: The SWAN-OM development process demonstrates complexities of designing an outcome measure for digital settings and single-sessions. We illustrate a route to measure creation that integrates into a digital service. The phased approach shows the value of participatory research with diverse young people to improve usability and face validity for a user-and-person-centre measure.

Symposium Paper 4
Counselling psychology trainees’ experiences of offering web-based therapy during the Covid-19 pandemic

Siddhi Jain

Authors: Siddhi Jain and Terry Hanley, University of Manchester

Aim/purpose: The emphasis that counselling and psychotherapy training programmes place upon developing web-based therapeutic skills is currently relatively limited. To ensure that individuals continued to access support during the Covid-19 global pandemic, trainee therapists had to shift to the digital space for all aspects of training, including offering online therapy at placements in lieu of in-person therapy as part supervised clinical hours required for qualification. With this in mind, this research study aimed to explore the experiences of counselling psychologists offering online therapy whilst completing doctoral training in counselling psychology.

Methodology: 12 counselling psychologists in training in universities across the United Kingdom participated in the study. Semi-structured interviews were conducted to understand the experiences that individuals had whilst offering online therapy at placements. The transcripts of the recorded interviews were analysed using thematic analysis.

Ethical approval: Ethical approval for this research study was sought from the University Research Ethics Committee of the School of Environment, Education, and Development at the University of Manchester.

Research findings: Analysis of the interview transcriptions led to the development of varied themes. These are:

  1. A shift in the therapeutic process
  2. The (digital) therapeutic space
  3. Training requirements and prior experience
  4. Professional identity of counselling psychology.

Research limitations: This research project looks at experiences of counselling psychologists in training only. Whilst the findings are transferable to other contexts, they do not refer to the experiences of qualified practitioners, or those completing other therapeutic training programmes.

Conclusions/implications: Findings from this research study outline the inadequate training provisions for online therapy for trainee counselling psychologists. Additionally, to ensure therapeutic services learn from the shifts that occurred during the pandemic, and make therapy more accessible to those who do not ordinarily approach in-person services, it highlights the need for therapy professions to acknowledge and adopt an identity shift to the digital paradigm. Further, it informs the need for future research, training, and clinical practice work that can aid working therapeutically in the digital space going forward. For instance, trainees benefitted from peer support groups and the development of communities to reflect upon their evolving practice.